Mailing Address:

P.O. Box 9

Grand Isle, VT 05458

Contact: Chairman, Richard Dreves 372-4534

Application for Water Service/Customer Agreement

I/We, the undersigned, being the occupant(s)*/owner(s) of the premises at:

Name:

Address: Apartment #

Legal Description of Property:

I/We in the Grand Isle Consolidated Water District, Town of Grand Isle, Vermont (the “District”), hereby request water service at the above address. The water service shall be used for the following purpose(s). Check the appropriate items and provide information as required.

*Deposit required, please see page 2

1. Residential Service o Single Family Unit o Multiple Family Unit; # of Units

2. Agricultural Service o House o Barn; Kind & # of Livestock

Estimated Daily Consumption Gallons

3. Commercial o Store o Service Station o Hotel/Motel; # of Units

o Other; Describe

Number of People Employed at Location

Services Provided

Estimated Daily Consumption Gallons

4. Industrial Average Number of People on Premises

Type of Operation

Estimated Daily Consumption Gallon

5. Temporary Service The estimated cost to the District for installation and removal is $ .

The total estimated consumption during this temporary service is

Gallons. Temporary service is requested from

6. Fire Service o Sprinkler o Other; Describe

Maximum Flow Rate

7. Is there presently water service at the above location? o Yes o No

Initial one of the following paragraphs:

o I/We certify that the premises named on page 1 is owned by me/us, and has a present value, in excess of any liens or encumbrances, in excess of one (1) year’s estimated annual charges, note below. We acquired ownership by deed recorded in Book______, Page_______, of the Land Records of Grand Isle, Vermont. The Lot/Map ID # is_____________________.

o I/We understand that I/we must pay a deposit equal to the estimated cost of installation, consumption, and removal of the temporary service, as shown below, and that this deposit will be held until I/we request a termination of service. I/We further understand that this deposit will then be applied to all outstanding charges for which I am/we are responsible, and that any balance remaining after the payment of such charges will then be refunded.

I/We agree:

To pay promptly all bills, rates, and other charges assessed by the District in connection with the furnishing of water service to the above address, together with all lawful costs of collection, including the District’s attorney’s fees.

To give reasonable, prior notice to the District’s Treasurer of any intention to terminate water service to the above address.

To assume full responsibility for all bills, rates, and other charges in connection with the furnishing of water service to the above address until such time as I/we have notified the District Treasurer of my/our intention to terminate such service.

To comply with the Rules and Regulations of the District as currently in effect and as may be adopted or amended, from time to time, including such emergency rules as the Board of Commissioners may adopt. A copy of the Water Ordinance is on file with the Town Clerk.

Signed: Date:

_______________________________________________________________________________________

TO BE COMPLETED BY THE GRAND ISLE CONSOLIDATED WATER DISTRICT

Charges for Water Service: Metered usage $ 30.00 per quarter (minimum usage)

Plus $3.29 per 1000gallons

Debt Retirement $ 82.50 per quarter_________________

Total per quarter: $102.50 per quarter + $3.29/1000 Gals

Service Connection Fee $3,000

Other Fees: Itemized

Accepted by: Date:

GRAND ISLE CONSOLIDATED WATER DISTRICT

P.O. Box 9

Grand Isle, VT 05458

PROCEDURE FOR APPLICATION AND CONNECTION TO THE

GRAND ISLE CONSOLIDATED WATER DISTRICT

RESIDENTIAL CONNECTION:

Complete and submit, with payment, the attached application for water service.
Receive permission for connection.
Obtain Service Connection Specification from water system operator or Town Clerk’s Office.
Hire contractor to install service to the specifications of the GICWD.
Contact water system operator to notify them of schedule for installation of service line. 48 hours notice is required. Operator can be reached at (802) 372-3865. Service line must be inspected before being buried to ensure compliance with specifications.
Service line must be a pressure class 200 pipe, and must be pressure tested to 100 psi or 1.5 times working pressure, whichever is greater.
Obtain water meter, from water system operator, for your plumber to install.
Contact operator to have meter installation inspected and water service turned on.
If you are a seasonal connection, operator will explain seasonal removal and installation procedure to you.

SUBDIVISION/COMMERCIAL/INDUSTRIAL/AGRICULTURAL CONNECTION:

Complete and submit, with payment, the attached application for water service.
Receive permission for connection.
Obtain Service Connection Specifications from water system operator or Town Clerk’s Office.
All main line distribution mains and service pipes must be Pressure Class 200. The GICWD will not accept ownership of anything less than PC 200 mains.
Submit site plan with water main locations, details, and specifications to GICWD for review prior to any construction.
Contact water system operator to notify them of schedule for installation of water lines. 48 hours notice is required. Operator can be reached at (802) 372-3865. Water lines must be inspected before being buried to ensure compliance with specifications.
Distribution mains must be pressure-tested to 200 psi and according to American Water Works Association (AWWA) Standards.
Distribution mains must be disinfected to AWWA Standards and proof of bacteriological testing must be submitted to the GICWD before water can be turned on.
Obtain water meter(s), from water system operator, for your plumber to install.
Contact operator to have meter installation(s) inspected and water service turned on.

GRAND ISLE CONSOLIDATED WATER DISTRICT

CONNECTION CHECKLIST

THIS CHECKLIST WILL BECOME PART OF CONNECTIONS PERMANENT RECORD

NAME OF OWNER(S)_____________________________________

LOCATION ______________________________________________

SUBDIVISION/COMMERCIAL/INDUSTRIAL/AGRICULTURAL CONNECTION:

Initials

SUBMIT APPLICATION WITH PAYMENT AT A MONTHLY

COMMISSIONER’S MEETING _____

*PERMISSION RECEIVED TO CONNECT. _____

*CONSTRUCTION DRAWINGS AND SPECIFICATIONS

SUBMITTED TO GICWD AND APPROVED BEFORE CONSTRUCTION _____

PROVIDE GRAND ISLE CONSOLIDATED WATER DISTRICT UTILITY EASEMENTS FOR ANY DISTRIBUTION LINES UNLESS LOCATED IN PUBLIC RIGHT OF WAY. _____

*DISTRIBUTION MAINS INSPECTED BEFORE BACKFILLED _____

*DISTRIBUTION MAINS PRESSURE TESTED TO 200 PSI _____

DISTRIBUTION MAINS DISINFECTED ACCORDING TO

AMERICAN WATER WORKS (AWWA) STANDARDS _____

*PROOF OF BACTERIOLOGICAL TESTING SUBMITTED TO GICWD _____

WATER METER(S) OBTAINED FROM OPERATOR FOR SERVICE CONNECTIONS (Residential checklists for individual connections will be

where appropriate) _____

*METER INSTALLATION(S) INSPECTED AND WATER TURNED ON _____

***ONLY A REPRESENTATIVE FROM GICWD CAN TURN WATER ON AND OFF. THE ABOVE CHEKCLIST MUST BE COMPLETED AND STARRED ITEMS INITAILED BY A GICWD REPRESENTATIVE(S) BEFORE WATER WILL BE TURNED ON. YOU MAY BE REQUIRED TO EXCAVATE THE LINE IF THE APPROPRIATE INSPECTIONS HAVE NOT BEEN MADE. IT IS THE RESPONSIBLILITY OF THE OWNER TO MAKE SURE THAT THIS CHECKLIST HAS BEEN COMPLETED IN FULL.

GRAND ISLE CONSOLIDATED WATER DISTRICT

CONNECTION CHECKLIST

THIS CHECKLIST WILL BECOME PART OF CONNECTIONS PERMANENT RECORD

NAME OF OWNER ________________________________________ Account No. ___________

PHYSICAL ADDRESS OF CONNECTION ___________________________________________________

RESIDENTIAL CONNECTION:

Initials

q SUBMIT APPLICATION WITH PAYMENT _____

q PERMISSION RECEIVED TO CONNECT. _____

q PROVIDE GICWD WITH AN EASEMENT IF REQUIRED _____

q (Easements are only required if curbstop is to be located on a

q private road or on owners property)

q WATER SYSTEM OPERATOR CONTACTED TO _____

NOTIFY OF SCHEDULE FOR INSTALLATION OF

SERVICE. 48 HOURS NOTICE REQUIRED.

q *SERVICE LINE INSPECTED BEFORE IT IS BURIED. _____

q *SERVICE LINE PRESSURE TESTED TO 100 PSI OR _____

1.5 TIMES WORKING PRESSURE, WHICHEVER IS GREATER.

q WATER METER OBTAINED FROM OPERATOR _____

q *METER INSTALLATION INSPECTED AND WATER TURNED ON _____

q SCHEDULE SEASONAL METER REMOVAL WITH OPERATOR _____

IF YOU ARE A SEASONAL USER.

***ONLY A REPRESENTATIVE FROM GICWD CAN TURN YOUR WATER ON AND OFF . THE ABOVE INSPECTIONS MUST BE PERFOMED BY A GICWD REPRESENTATIVES BEFORE THE WATER WILL BE TURNED ON. YOU WILL BE REQUIRED TO RE EXCAVATE THE WATER LINE IF AN AUTHORIZED REPRESENTATIVE OF THE GICWD HAS NOT INSPECTED IT. IT IS THE RESPONSIBILITY OF THE PROPERTY OWNER TO MAKE SURE THAT THIS CHECKLIST HAS BEEN COMPLETED IN FULL.***